Is coverage of S. aureus necessary in cellulitis/erysipelas? A literature review

BACKGROUND

Empirical treatment of patients with cellulitis/erysipelas usually targets both streptococci and methicillin-sensitive S. aureus (MSSA). However, the recommendation to empirically cover MSSA is weak and based on low-quality evidence.

METHODS AND OBJECTIVE

A systematic review was conducted in PubMed and clinical trial registries to assess the role of S. aureus in cellulitis/erysipelas and the need for empirical MSSA coverage.

RESULTS

Combined microbiological and serological data, and response to penicillin monotherapy suggest that streptococci are responsible for the vast majority of cases of cellulitis/erysipelas. However, most cases are non-culturable and the specificity of microbiological and serological studies is questionable based on recent studies using molecular techniques. According to epidemiological data and three randomized controlled trials, empirical coverage of methicillin-resistant S. aureus (MRSA) is not recommended for most patients, despite the high prevalence of MRSA in many areas. If MRSA is indeed not an important cause of uncomplicated cellulitis/erysipelas, then the same may apply to MSSA. Based on indirect comparison of data from clinical studies, cure rates with penicillin monotherapy (to which most MSSA are resistant) are comparable to the cure rates reported in many studies using wider-spectrum antibiotics.

CONCLUSION

Considering the limitations of microbiological studies in identifying the pathogens responsible for cellulitis/erysipelas, treatment needs to be guided by clinical trials. Trials comparing penicillin or amoxicillin monotherapy to MSSA-covering regimens are needed to definitively answer whether empirical coverage of MSSA is needed and to identify the subset of patients that can be safely treated with penicillin or amoxicillin monotherapy.

Warmer Weather as a Risk Factor for Cellulitis: A Population-based Investigation

Background

The incidence of cellulitis is highly seasonal and this seasonality may be explained by changes in the weather, specifically, temperature.

Methods

Using data from the Nationwide Inpatient Sample (years 1998 to 2011), we identified the geographic location for 773719 admissions with the primary diagnosis (ICD-9-CM code) of cellulitis and abscess of finger and toe (681.XX) and other cellulitis and abscess (682.XX). Next, we used data from the National Climatic Data Center to estimate the monthly average temperature for each of these different locations. We modeled the odds of an admission having a primary diagnosis of cellulitis as a function of demographics, payer, location, patient severity, admission month, year, and the average temperature in the month of admission.

Results

We found that the odds of an admission with a primary diagnosis of cellulitis increase with higher temperatures in a dose-response fashion. For example, relative to a cold February with average temperatures under 40° F, an admission in a hot July with an average temperature exceeding 90°F has 66.63% higher odds of being diagnosed with cellulitis (95% confidence interval [CI]: [61.2, 72.3]). After controlling for temperature, the estimated amplitude of seasonality of cellulitis decreased by approximately 71%.

Conclusion

At a population level, admissions to the hospital for cellulitis risk are strongly associated with warmer weather.

Aetiology and clinical features of facial cellulitis: a prospective study

BACKGROUND

In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis.

METHODS

Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages.

RESULTS

Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities.

CONCLUSIONS

Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.

Increasing Incidence, Cost, and Seasonality in Patients Hospitalized for Cellulitis

Using data from the National Inpatient Sample, 1998-2013, we show that hospitalizations for cellulitis have approximately doubled. Costs increased by 118% to $3.74 billion annually. In addition, hospitalizations for cellulitis are highly seasonal, peaking in summer months: incidence during the peak month of July is 35% higher than in February.

[Survey of general practitioners management of erysipelas]

PURPOSE

A few studies only have focused on ambulatory management of erysipelas.

METHODS

To assess the diagnostic and therapeutic management of erysipelas by general practitioners, and their adherence to the French Society of Infectious Diseases and Dermatology joint 2000 recommendations, we surveyed 114 general practitioners during a 1 year period (from May 1st, 2005 to April 30th, 2006).

RESULTS

Seventy-three general practitioners accepted to participate to the study and 54 cases of erysipelas were reported. Median age of patients was 63 years (range, 18-94) and sex ratio was 0.77. Lower limbs were affected in 83% out of the cases. A skin lesion was reported in 65% of the cases. None of the 15 doppler ultrasonography that were performed identified deep vein thrombosis. Five patients (9%) were initially hospitalized. Only 18% out of the patients were treated by amoxicillin. Most prescribed antimicrobial agents were pristinamycin (31%) and amoxicillin-clavulanate (27%). Median duration of treatment was 10 days. Six patients received an anti-inflammatory drug. Among the 44 patients who had a follow-up visit, 37 patients (84%) recovered and two patients were hospitalized after this follow-up assessment. Two patients experienced a recurrence of erysipelas during the study.

CONCLUSION

As previously reported in the literature, outcome of erysipelas after ambulatory management remains excellent, although recommendations are poorly followed.

Burden of illness of bacterial cellulitis and erysipelas of the leg in the Netherlands

BACKGROUND

Information on the prevalence of bacterial cellulitis (BC) and erysipelas (ER) of the leg (BCERL) is sparse and dependent on the definitions used. There is no information available on the number of hospitalized and non-hospitalized patients with BCERL, and related treatment costs.

OBJECTIVE

The purpose of this study was to assess the burden of illness for BCERL in the Netherlands in 2001.

METHODS

Data were obtained from different linked databases. Hospital information was obtained from the National Morbidity Registration (known in the Netherlands as the LMR), which includes all Dutch citizens, using ICD-9-CM codes. The number of patients not admitted to hospital was estimated using a subsample with data from general practitioners (GPs) (N = 50,000). These data were extrapolated using age/gender and disease-specific standardization. The subsample was used to assess the location of the infection. Reimbursement costs were available for all resources.

RESULTS

In 2001, approximately 28,000 patients presented with either BC or ER of the leg. Of these patients, 2,200 were admitted to the hospital and 4-6% had two or more episodes of ER/BC in 2001. The average costs per hospitalization for BCERL were 5,346 euros, accumulating to more than 14 million euros in 2001. Although only 7% of all patients were hospitalized, 83% of the total treatment costs could be attributed to hospitalization.

CONCLUSIONS

BCERL are common and serious infections in the Netherlands. Hospitalization occurs in only one in 14 patients but contributes more than 80% of the total costs, which accumulate to 17 million euros a year.

Recurrent Erysipelas: 47 Cases

BACKGROUND

Recurrence is a common complication of erysipelas (cellulitis).

OBJECTIVES

Todescribe the characteristics of patients with recurrent erysipelas and thereby, identify potential risk factors and evaluate prophylaxis efficacy.

METHODS

Data were retrospectively recorded from the files of 47 patients admitted to hospital between 1995 and 2003 for erysipelas recurrence. Studied variables included: general condition, regional and local factors, e.g. broken cutaneous barrier. Patient characteristics were used to construct tree-based models according to the classification and regression tree methodology.

RESULTS

Our patients suffered a mean of 4.1 recurrences. Cutaneous barrier disruption was observed in 81%, mainly intertrigo (60%). Antibiotic prophylaxis was taken by 68% of the patients for 30.6 months. After 1 and 2 years, 84 and 72% of the patients, respectively, were recurrence-free.

CONCLUSION

Our results showed that erysipelas recurrence has the same risk factors as single episodes and underlines the potential benefit of oral or parenteral antibiotic prophylaxis to prevent recurrences.

Risk Factors for Erysipelas of the Leg in Tunisia: A Multicenter Case-Control Study

BACKGROUND

Risk factors for erysipelas (cellulitis) were rarely evaluated in controlled studies. Regional variations of these risk factors have never be assessed.

OBJECTIVE

To assess risk factors for erysipelas of the leg in Tunisia.

SUBJECTS AND METHODS

Case-control study in seven hospital centers in Tunisia. Cases were 114 consecutive patients with erysipelas of the leg [sudden onset (<24 h) of a well-demarcated dermo-hypodermatitis with fever or chills]. Two controls were matched to each case for age, sex, and hospital (n = 208). Main outcome measures are local and general suspected risk factors for erysipelas of the leg.

RESULTS

In multivariate analysis, disruption of the cutaneous barrier (i.e. traumatic wound, toe-web intertrigo, excoriated leg dermatosis or plantar squamous lesions) and leg edema were independently associated with erysipelas of the leg, with respective odds ratios of 13.6 (95% confidence interval: 6.0-31) and 7.0 (1.3-38). No association was observed with diabetes, alcoholism, or smoking.

CONCLUSIONS

We confirmed the major role of local risk factors and the minor role of general risk factors for erysipelas of the leg, in a setting different than the one previously studied. Detecting and treating toe-web intertrigo and traumatic wounds should be considered in the prevention of erysipelas of the leg.

[Treatment of erysipelas in Germany and Austria--results of a survey in German and Austrian dermatological clinics]

BACKGROUND

Erysipelas is a severe soft tissue infection usually caused by streptococci. The infection is restricted to the dermis and subcutaneous tissues. Treatment with antibiotics is essential. Many different therapeutic regimens are recommended, based mainly on empirical data and only partly proven by clinical studies.

MATERIAL AND METHODS

Our aim was to evaluate the treatment of erysipelas in Germany and Austria by means of a questionnaire and to derive treatment recommendations from this data.

RESULTS AND CONCLUSION

The majority of clinics treat patients with erysipelas as inpatients with intravenous antibiotics. The usual first line treatment is group G penicillin (80%). Other choices include amino-penicillins (11%), cephalosporins (16.5%) and anti-staphylococcal penicillins (6.9%) are used. As second line antibiotics macrolides (63.5%), clindamycin (52.5%), penicillins (18.5%), cephalosporins (40%) and fluoroquinolones (20.5%) are mentioned. Carbapenems, tetracyclines, nitroimidazoles, glycopeptides, aminoglycosides, cotrimoxazole, fusidic acid and fosfomycin are used rarely. The median treatment duration is 10 days. Adjuvant measures are anticoagulation, non-steroidal anti-inflammatory agents, dressings, immobilization and treatment of local predisposing factors such as interdigital tinea.

[Management of erysipelas in French hospitals: a post-consensus conference study]

INTRODUCTION

A prospective hospital-based survey on the management of bacterial dermal-hypodermal infections was conducted before the consensus conference "How should Erysipelas-Necrotic Fasciitis be managed?". The results of the survey were circulated early in 2001. To assess the eventual impact of the guidelines from the conference on hospital practices with regard to erysipelas, we conducted a new prospective survey at the end of 2002.

PATIENTS AND METHODS

The questionnaire used was identical to that of the 2001 survey. It collected, anonymously, data on the clinical characteristics, supplementary examinations conducted (bacteriology, imaging), initial treatment and outcome. The questionnaire was mailed to the departments of dermatology, internal and/or infectious diseases and intensive care that had replied to the first survey (n = 124). The patients eligible for inclusion were those hospitalized between 09/01/2002 and 11/30/2002. Statistical analysis compared the results with those of the preceding survey.

RESULTS

The files of 245 patients were collected that came from 41 departments (15 from university hospitals, 23 from general hospitals and 3 from military hospitals) and 235 of whom had erysipelas. For those with erysipelas, the mean age was of 65 +/- 2.5 years, the M/F sex ratio was of 0.66 and the localization was the leg in 89.5 p. 100 of cases. A Doppler of the legs was performed in 33 p. 100 of cases. The initial antibiotherapy was penicillin G in 38 p. 100 of cases and pristinamycine in 18 p. 100 (others: 44 p. 100). The route of administration was initially intravenous in 73 p. 100 of cases. An anti-coagulant was associated in 60 p. 100. The outcome was favorable in 94 p. 100 of cases, with a mean duration of hospitalization of 11.2 +/- 1.2 days and antibiotics of 17.7 +/- 1.3 days. Dopplers and the blood cultures were performed more frequently than before the consensus conference, but no difference was found in the antibiotics or adjuvant therapies.

DISCUSSION

The follow-up survey showed the stability of hospital practices concerning erysipelas, notably with regard to treatment. In contrast, the clear tendency in limiting the supplementary examinations is in agreement with the consensus conference.

Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study

OBJECTIVE

To assess the role of foot dermatomycosis (tinea pedis and onychomycosis) and other candidate risk factors in the development of acute bacterial cellulitis of the leg.

METHODS

A case-control study, including 243 patients (cases) with acute bacterial cellulitis of the leg and 467 controls, 2 per case, individually matched for gender, age (+/-5 years), hospital and admission date (+/-2 months).

RESULTS

Overall, mycology-proven foot dermatomycosis was a significant risk factor for acute bacterial cellulitis (odds ratio, OR: 2.4; p < 0.001), as were tinea pedis interdigitalis (OR: 3.2; p < 0.001), tinea pedis plantaris (OR: 1.7; p = 0.005) and onychomycosis (OR: 2.2; p < 0.001) individually. Other risk factors included: disruption of the cutaneous barrier, history of bacterial cellulitis, chronic venous insufficiency and leg oedema.

CONCLUSIONS

Tinea pedis and onychomycosis were found to be significant risk factors for acute bacterial cellulitis of the leg that are readily amenable to treatment with effective pharmacological therapy.

Determinants of severity for superficial cellutitis (erysipelas) of the leg: a retrospective study

BACKGROUND: Superficial cellulitis (erysipelas) of the leg is a frequent infectious disease with a favorable outcome, whereas some patients present a serious disease. The determinants of severity for superficial cellulitis (erysipelas) of the leg have not yet been clearly established. In order to determine the characteristics of patients presenting with severe superficial cellulitis of the leg, we analyzed patients with favorable and unfavorable outcome. METHODS: The records of 167 patients referred to Rouen University Hospital for non-superficial cellulitis of the leg were analyzed. Two severity groups of patients were retrospectively defined. Patients in the severe group either died secondary to infection during hospital stay or were hospitalized for a duration at least equal to the 90th percentile (i.e., >21 days of hospitalization). The remaining patients were considered as presenting with non-severe cellulitis. Potential determinants of severity were analyzed by univariate and multivariate analysis based on logistic regression. RESULTS: From univariate analysis, the following general factors were positively associated with severity: advanced age, arterial hypertension, diabetes mellitus, elevated leukocytosis, and elevated neutrophilia. The local factors associated with severity were ulcer of the leg and arteriosclerosis obliterans of the leg. From multivariate analysis, only age (P=0.004), diabetes mellitus (P=0.01), and leukocytosis (P=0.04) appeared to be independently associated with severity. A close to significant association was also found with arteriosclerosis obliterans of the leg (P=0.07). Whereas general complications occurred more frequently in the severe group, no such difference was observed for local complications. CONCLUSIONS: Determinants of severity for superficial cellulitis of the leg include high age and associated medical conditions. Aged patients and patients with diabetes mellitus, elevated leukocytosis, or possibly arteriosclerosis obliterans of the leg should preferably be hospitalized for specific care of associated conditions to avoid the occurrence of general complications.

Intramuscular bipenicillin vs. intravenous penicillin in the treatment of erysipelas in adults: randomized controlled study

The objective of the study was to evaluate the efficacy of intramuscular penicillin: mixture of benzyl penicillin and procain penicillin (2 MU x 2 times daily) and intravenous benzyl penicillin (4 MU x 6 times daily) in the treatment of hospitalized adult patients with erysipelas. A prospective randomized unicentric trial was conducted. In total, 112 patients entered the study; 57 in the intramuscular group and 55 patients in the intravenous group completed the trial. The failure rate was 14% for intramuscular group and 20% for the intravenous group (P = 0.40). Local complications such as of the leg abscesses were observed in the two groups (intravenous 9.1%, intramuscular 7%; P = 0477). Of the patients treated with intravenous benzyl penicillin, 25.5% presented complications related to the route (venitis). Intramuscular penicillin should be considered an effective and well-tolerated treatment of erysipelas in adult patients.

Érysipèle. Profil épidémiologique, clinique et évolutif dans la région de Marrakech (100 observations)

OBJECTIVE

We aimed to determine the epidemiological and clinical profile, and to study the evolution of this disease in the Marrakech region.

MATERIAL AND METHODS

We retrospectively studied all patients with a diagnosis of erysipelas admitted in the Department of Dermatology from 1990 to 2002, in the Marrakech Mohamed VI hospital.

RESULTS

A total of 100 patients were included in the study, 58 male (58%) and 42 female (42%) patients, age range 9-95 years (mean age: 47 years). The lesions were most frequently located on the lower limbs (87% of the cases), with 82 cases occurring in the legs, whereas the face was affected in 10% of the cases. Erysipelas relapsed in 12 patients (12%). All patients had at least one risk factor: portal of entry (80 cases, with 67 cases of toe web intertrigo), obesity (10% of the cases), lymphedema (6% of the cases), diabetes (3% of the cases). The first line treatment was intravenous penicillin G in 76 cases (76%). Satisfactory results were observed in 78% of the cases.

COMMENTS

Erysipelas is common in hospital environment. An early penicillin therapy associated to the treatment of the portal of entry leads to satisfactory results.

Recurrent erysipelas: risk factors. Risikofaktoren fur Rezidiverysipele

BACKGROUND

Several systemic and regional risk factors have been described for erysipelas. However, those predisposing for recurrent episodes are not well defined.

MATERIALS AND METHODS

We performed a retrospective analysis of 574 patients hospitalized in our institution during a 3 year period. The analysis included demographic, epidemiologic, and medical chart review data with special attention to background disorders. The patients with single and recurrent episodes of erysipelas were compared.

RESULTS

The recurrent cases occurred mainly in the lower limb with several risk factors that were statistically more common than in the single episode group including overweight, venous insufficiency, lymphedema, tinea pedis, and previous regional surgical intervention or trauma.

CONCLUSIONS

Patients with erysipelas, especially when it involves the lower limb, should be instructed to reduce weight, control venous insufficiency and/or lymphedema and to emphasize prevention and treatment of tinea pedis. The role of prophylactic antibiotics requires further study.

Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study

A prospective, randomized, multicentre trial was conducted to evaluate the efficacy and safety of roxithromycin (150 mg b.i.d. orally) and penicillin (2.5 MU x 8 daily intravenously, then 6 MU daily orally) in the treatment of hospitalized adult patients with erysipelas. Seventy-two patients entered the study. Thirty-one patients in the roxithromycin group and 38 patients in the penicillin group completed the trial. The overall efficacy rates (cure without additional antibiotics) were 84% (26/31) in the roxithromycin group and 76% (29/38) in the penicillin group (P = 0.43). No side-effects were observed in the roxithromycin-treated patients whereas rashes occurred in two cases in the penicillin group, leading to exclusion from the study. Oral roxithromycin can thus be considered an effective and well-tolerated treatment for erysipelas in adult hospitalized patients.

Facial erysipelas: report of a case and review of the literature

The diagnosis of erysipelas is usually made clinically. Features that help distinguish erysipelas are acute onset, erythema, warmth, edema, pain, fever, and isolated regional involvement with clearly demarcated margins. High ASO titers and response to penicillin therapy are reassuring. Simple uncomplicated erysipelas or cellulitis in adults can usually be treated on an outpatient basis. Extensive facial involvement with fever and a toxic appearance warrants hospitalization. Facial cellulitis or erysipelas in children, unless quite limited, requires hospitalization because of the high risk of Hemophilus influenzae infection and sepsis. Hospitalized patients should show visible signs of resolution and be afebrile for at least 24 hours prior to discharge. They should be maintained on oral antibiotic therapy at home for an additional 7 to 10 days.

Erysipelas complicating chronic discoid lupus erythematosus of the face--a case report and review of erysipelas

We present a case of erysipelas which complicated chronic discoid lupus erythematosus (CDLE) of the face. The diagnosis and implications for management are discussed. The changing epidemiology and clinical spectrum of erysipelas are reviewed.

Erysipelas and group G streptococci

In a prospective study, 73 patients with erysipelas were studied bacteriologically, serologically and clinically. Pathogenic bacteria were isolated from 41% of the patients. Group G streptococci (GGS) were found as frequently as group A streptococci (GAS), in 12.5% and 15% of patients, respectively. Staphylococcus aureus was isolated in 10%, and streptococci groups B, C and D were isolated from one case each. Raised ASO titres were found among patients with GAS and GGS, while a rise in ADNase B titre was found only in patients with GAS. Patients with GGS tended to be older than other patients. Otherwise no clinical differences were noticed. The infection was located to the lower extremity in 68%. Predisposing factors were observed in 44% of the patients, predominantly local circulatory insufficiency and malignancies. In 55% a possible portal of entry was present. GGS seems to be a common cause of erysipelas, especially among patients older than 50 years.